MP-200 Missing Participants Program - Plan Information for Defi

Missing Participants Program
Plan Information for Defined Contribution Plans
□ Amended Filing

Form MP-200

Approved OMB 1212-0069
Expires XXXX

Clear Form

Part I — General Information

1 Plan information
a Plan name
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _
d Plan contact
(1) Name
(2) Company
(3) Street address
(4) City
(5) State
(7) Telephone _ _ _-_ _ _-_ _ _ _

c 8-digit PBGC Case # _ _ _ _ _ _ _ _

(6) Zip

ext_ _ _ _ _ _ (8) email

e Is plan electing to be a transferring plan or a notifying plan? (check applicable box) □ Transferring □ Notifying
(1)
(2)
(3)
2 Number of individuals reported in
Account $250 or less
Account more than $250
Total
applicable attached schedules
0

(Notifying plans may omit breakdown)

3 Amended filings only - Did the original filing contain information on anyone who is no longer considered
missing (i.e., has anyone been removed from the applicable Schedule B)? (attachment required if “Yes”)

□ Yes
□ No

Part II — Additional Information for Transferring Plans
________

4 Benefit transfer date
5 Amounts owed to PBGC for missing distributees reported in this filing
a Aggregate account balances [sum of item 5 from all Schedules B]
b Administrative fee [$35 x number reported in column (2) of item 2]

$ 0.00

c Total [item 5a + item 5b]

$ 0.00

6 Reconciliation (amended filings only)
a Amounts previously paid in conjunction with prior Forms MP-200 for this plan
b Underpayment/(overpayment) [item 5c – item 6a]
7 Payment method

□ Pay.gov

□ Other electronic funds transfer

□ Paper check

8 Default beneficiary provision — Does the plan have a default beneficiary designation provision?

□ Yes □ No

Part III — Certification
9 Certification – The plan administrator or qualified termination administrator must sign and complete this item.
I certify that to the best of my knowledge and belief that all the information in this filing is true, correct and complete and
has been determined in accordance with PBGC's Missing Participants regulations and instructions, including the diligent
search requirements of 29 CFR § 4050.204.

Name of person signing:

First name

Last name

email

_ _ _ -_ _ _ - _ _ _ _ ext _ _ _ _ _ _
Telephone

Signature

Date

Schedule A
(Form MP-200)

Individual Information - Notifying Plans
This Schedule A is #

of

Approved OMB 1212-0069
Expires XXXX

(insert total # of Schedules A included in this filing)

Click here to add another Sch A

Part I — Plan/Financial Institution Information
1 Plan information
a Plan name
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _
2 Financial institution information
a Financial institution name

c 8-digit PBGC Case # _ _ _ _ _ _ _ _

b Financial institution contact information
(1) Name
c Financial institution address
(1) Street address
(2) City

(2) Telephone _ _ _ -_ _ _ - _ _ _ _(3) email

(3) State

(4) Zip

Part II — Individual Information

Complete items 3-4 for each missing individual whose DC account was transferred to a financial institution that you are reporting
to PBGC. Use additional schedules as needed.

3 Missing distributee information
a Identifying information
(1) Name (last, first, middle)

(2) Date of birth _ _ _ _ _ _ _ _

(3) Social security number _ _ _-_ _-_ _ _ _
b Last-known address
(1) Street address
(2) City

(3) State

(4) Zip

c Account information
(1) Account number

(2) Account balance transferred

4 Amended filing code — If this is an amended filing, enter the applicable code to indicate whether
information for this missing distributee has changed or is being reported for the first time (see instructions).

_____

3 Missing distributee information
a Identifying information
(1) Name (last, first, middle)

(2) Date of birth _ _ _ _ _ _ _ _

(3) Social security number _ _ _-_ _-_ _ _ _
b Last-known address
(1) Street address
(2) City

(3) State

(4) Zip

c Account information
(1) Account number

(2) Amount balance transferred

4 Amended filing code — If this is an amended filing, enter the applicable code to indicate whether
information for this missing distributee has changed or is being reported for the first time (see instructions).

_____

Individual Information - Transferring Plans

Schedule B
(Form MP-200)

Approved OMB 1212-0069
Expires xxxxxx

This Schedule B is # _______ of __________ (insert total # of Schedules B included in this filing)

Part I — Plan Information
1 Plan information
a Plan name_________________________________________________________________________________
b Employer identification number/plan number _ _ -_ _ _ _ _ _ _/_ _ _

c 8-digit PBGC Case # _ _ _ _ _ _ _ _

Part II — Individual Information
2 Missing distributee information
a Name (last, first, middle) ___________________________________________________
c Social Security Number _ _ _-_ _-_ _ _ _
b Date of birth _ _ /_ _/_ _ _ _
d Last-known address
(1) Street address______________________________________________________________
(2) City_______________________________

(3) State _____

(4) Zip __________

e Other name(s) ever used (if known) ___________________________________________________________
f Type of missing distributee

□ Participant

□ Beneficiary (if checked, see instructions re: required attachment)

Part III — Transfer Amount
3 Portion attributable to pre-tax contributions
4 Portion attributable to post-tax contributions

_____________
Contributions

Investment Earnings

a Qualified Roth transfers

____________

b Non-qualified Roth transfers

_____________

_____________

____________

c Other

_____________

_____________

____________

5 Total transfer amount

_____________

6 Is any portion of the missing distributee’s benefit attributable to non-US-source income?
□ Yes □ No (Attachment required if “Yes”)
Part IV— Miscellaneous Information
7 Non-qualified Roth transfer - If the transfer amount includes a non-qualified Roth transfer, enter
the date the first Roth contribution was made. Complete only if amounts are reported in 4b

_ _ /_ _/_ _ _ _

8 Beneficiary Information Complete only if “Participant” is checked in item 2f

a Do plan records contain a valid beneficiary election form? If yes, attach a copy of the form and
complete items (b)-(d) with respect to the designated beneficiary.

□ Yes □ No

b Name ______________________________________ c Social Security number _ _ _-_ _-_ _ _ _
d Relationship ____________________________________________________
9 Amended filing code — If this is an amended filing, enter the applicable code to indicate whether
information for this missing distributee has changed or is being reported for the first time (see
instructions).

_______